Basic Information
| Provider Information | |||||||||
| NPI: | 1295916534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTICE | ||||||||
| FirstName: | ADENA | ||||||||
| MiddleName: | CAROL | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1116 BROADLEAF RD | ||||||||
| Address2: | |||||||||
| City: | LOUISA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 412306017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062057385 | ||||||||
| FaxNumber: | 6064339690 | ||||||||
| Practice Location | |||||||||
| Address1: | 1116 BROADLEAF RD | ||||||||
| Address2: | |||||||||
| City: | LOUISA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 412306017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062057385 | ||||||||
| FaxNumber: | 6064339690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2007 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.